Download Lab Exercise 2: Order Checks

The CAHIMS Exam Preparation Course
and the CAHIMS exam are the result of
collaboration between the Life Science
Informatics Center at Bellevue College
and the Healthcare Information and
Management Systems Society (HIMSS).
Significant content found in the CAHIMS
Exam Preparation Course stems from the
Office of the National Coordinator for
Health Information Technology. Creation
of the CAHIMS Exam Preparation Course
and the CAHIMS exam was made
possible through support from the National
Science Foundation (NSF).
Curriculum Team:
Margaret Schulte, DBA
Michèle Royer, PhD
Nathan Savage, MLIS
Section 2 - Technology Environment
Lesson 2.2 - Electronic Health and Medical Records
Configuring Electronic Health Records: Implementing Clinical Decision Support
Lab Exercise 2: Order Checks
Order checking is a component of the Order Entry process. It is based on a system of
rules which reviews orders to see if they meet defined criteria that require further action
by the provider before the order can be processed. If the specific order meets the
criteria, an electronic message is transmitted to the ordering provider before the order is
completed. Examples of specific Order Checks are: duplicate order, duplicate drug
class order, adverse reaction, and drug-lab interaction. When there is a message
warning of possible problems, the provider can choose to cancel the order or override
the order check by entering a justification and then placing the order.
Order Checks are real-time processes that occur during the placing of an order. Order
check messages are displayed during the ordering process. Before orders are
transmitted to the Laboratory, Pharmacy and other modules of the EHR, orders are
subjected to Order Checking algorithms where the order is evaluated by an expert
system rule against data from patient files. If one or more of the rules for the order is
met, order check messages are transmitted to the clinician placing the order. For
example, if a provider prescribes an antibiotic for a patient, the order is checked to
ensure that the patient is not allergic to that medication.
Order Checks can be set as Mandatory order checks. If an Order Check is set as
mandatory, users are not authorized to change the mandatory status and the order
check will be in effect for all authorized users. Members of the Clinical Application
Coordinator user class are given the access to enable mandatory Order Checks. If the
Order Check is not set as mandatory, other users classes such as doctors can turn
specific Order Checks on or off.
Clinical notes: Using order checks reduce the incidence of errors. For example,
consider a patient who is to be admitted to the hospital, and has been on a cardiac
medication called atenolol, which is a class of drug termed beta-blockers, for the last
year. Now consider that the physician admitting the patient to the hospital enters an
order for another drug called metoprolol, which is also a beta-blocker. The combination
of both beta-blockers may cause serious side-effects, but the order checking software is
able to identify that the two medications are in the same class, and fires a duplicate
drug class order in real time, as the physician is placing the order for metoprolol. The
physician is able to cancel her order, and the patient is spared a potential adverse
reaction.
This lab exercise will guide students through the process of managing Order Checks in
VistA and then require them to demonstrate they have mastered this function with a
hands-on activity.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 1
Exhibit 1: List of Order Checks
Allergy-contrast Media Interaction
Allergy-Drug Interaction
Aminoglycoside Ordered
Biochem Abnormality for Contrast
Clozapine Appropriateness
Critical Drug Interaction
CT & MRI Physical Limitations
Dangerous Meds for PT > 64
Dispense Drug Not Selected
Duplicate Drug Class Order
Duplicate Drug Order
Duplicate Opioid Medications
Duplicate Order
Error Message
Estimated Creatinine Clearance
Glucophage-Contrast Media
Glucophage-Lab Results
Lab Order Freq Restrictions
Missing Lab Tests for Anglogram
Mp Allergy Assessment
Order Checking Not Available
Polypharmacy
Recent Barium Study
Recent Oral Cholecystorgram
Renal functions Over Age 65
Significant Drug Interaction
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 2
Instructions for Users to Enable or Disable Order Checks in CPRS (role = Clinical
Coordinator)
1. Double click on the VistA_Apps folder installed on your desktop
2. Double click the CPRS Chart icon
3. Log on to CPRS using your Clinical Coordinator access and verify codes.
4. Select a patient and click <OK>
5. From the coversheet tab, Select <Tools> from menu bar
6. Select <Options>
7. Select <Order Checks>
Note: Order Check screen will display
Exhibit 2: CPRS Order Checks
8. Users Enable or Disable Order Checks which are not Mandatory by selecting an
Order Check or de-selecting the Order Check.
9. After you have gone through the Order Check list and made your selections, click
<Apply>, then click <OK> (to save the changes).
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 3
Instructions for Placing an Inpatient Medication Order(s) (role: Doctor)
Clinical notes: In this activity, we will simulate the procedure that a physician would
follow to order a medication when using VistA. CPOE, or computerized provider order
entry, allows clinicians to enter orders directly into the system, rather than having orders
transcribed into the system by a third party. Eliminating intermediary steps reduces task
duplication, and also decreases the potential of transcription errors.
1. Double click on the VistA_Apps folder installed on your desktop
2. Double click the CPRS Chart icon.
3. Log on to CPRS using access and verify codes of a Doctor.
4. Select an Inpatient and click <OK> (An inpatient can be selected by selecting a
ward first, and then selecting one of the patients from the ward.)
5. Select <Orders>.
6. Select <Inpatient Medications> Note: When medication is entered, the medication
will display on Orders tab as an unsigned order.
Note: For Patient Safety purposes, only one user can enter orders on the same patient
at the same time; the system will automatically generate an alert displaying the current
user placing orders as shown in Exhibit 3 when doctor3 tries to place an order while
doctor 1 is accessing Patient Nine’s file.
Clinical notes: This is to avoid the situation when two clinicians could simultaneously
order conflicting medications that might interact with one another, or write orders that
might cause other deleterious effects. It also prevents duplicate orders being entered by
different clinicians at the same time.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 4
Exhibit 3 – Alert Generated from Multiple Providers Placing Orders
7. Select a medication.
8. Select <Quit>.
9. A screen will appear where the electronic signature can be entered or the order can
be cancelled. The electronic signature is DOCTORX where X=1 to 99
10. Feel free to repeat the process of selecting different medications to get a feel for
how the functionality works. Keep in mind that different medications have different
parameters for prescribing.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 5
Student Exercise
Log into CPRS as a doctor:
1. Double click on the VistA_ Apps folder installed on your desktop.
2. Double click the CPRS Chart icon.
3. Log on to CPRS Chart using your Doctor access and verify codes.
Clinical notes: Typically, a physician will select the patient, and then place orders based
on clinical considerations. For example, consider a patient with diabetes mellitus (a
medical condition where the blood glucose is too high). The physician has two
pharmacological options to bring the blood sugar down quickly – use oral medications
(pills) or insulin (an injection). In this example, let us suppose the physician wants to
order glipizide – an oral tablet that brings down blood sugars. The physician will need
to enter an order for glipizide tablets, and the pharmacy can then dispense the
medication. The nurse will subsequently administer glipizide to the patient, and may
subsequently check glucose levels to make sure the numbers are improving.
The second order is for a medication delivered by a different route –in this case an
injection of a multivitamin. Note that the route of delivery is specified at the time of
placing the order. This is because medications may be available as different
preparations. While glipizide is only available by the oral route, multivitamins may be
available in tablet, capsule (both oral) or injectible form. The appropriate preparation
and delivery route will determine the selection choice during order entry.
Configure and Test Order Checks:
4. Select an Inpatient.
5. Review Order Checks - Enable - Duplicate Drug Order (if this order check is not
enabled).
6. Place two separate orders for Glipizide Tab. Check the inpatient medication
menu to see if it is available. If not, you will have to order from the outpatient
medication menu.
7. Use Print Screen or screen capture functionality to make a copy of the Order Check
message in CPRS.
8. Do Not Process orders – Cancel/Discontinue orders.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 6
9. Select an Inpatient. (Nine, Patient is a good one to work with as he has a good
selection of associated clinical information).
10. Place an Inpatient order for a multivitamin injection from Inpatient Medication
menu item.
11. Use Print Screen or screen capture tools to save and copy Order Check message(s)
in CPRS to your work folder.
This work is funded by the National Science Foundation
Advanced Technological Education Grant 1003223
Page 7